A healthcare provider, such as a pharmacy, pharmacist, doctor's office, urgent care center, physician, hospital, or the like provides numerous healthcare related services to patients. One of these services is to, at times, provide prescription medications, products, or services to a patient. Typically, a healthcare transaction, such as a predetermination of benefits transaction, healthcare claim transaction, prescription claim or billing request, healthcare order transaction, or e-prescription transaction (e.g., electronic prescription order transaction, e-script, or e-prescription), is generated by the healthcare provider and sent, either directly or indirectly, to a claims processor for adjudication. In some cases, the healthcare transaction is sent to a claims processor by way of a service provider or switch. The healthcare transaction typically includes information that identifies the patient, the medication, product, or service being requested, the healthcare provider (either the prescriber, pharmacy, or both), and the benefit plan, insurer, or government-funded payor for the patient.
In certain situations, in order for the patient to receive a requested medication, product, or service, the prescriber (e.g., physician, hospital, nurse or any person legally permitted to prescribe medications, products, and/or services) was supposed to first have received prior authorization from the benefit plan, insurer or government-funded payor. In situations where this has not occurred, the claims processor associated with the benefit plan, insurer, or government-funded payor may reject, as part of the adjudication, a healthcare transaction requesting prior authorization for the requested medication, product, or service. A prior authorization rejection or request is one where the pharmacy benefits manager, insurance company, or other benefits payor initially blocks a patient's coverage for a prescribed medication, product or service, and requires that the prescriber contact the payor to provide additional information to the payor. For example, the payor may want to make sure what is being prescribed is what the doctor intended to prescribe, that the medication is clinically appropriate, that a generic or other equivalent medication cannot be substituted for the prescribed medication, or that other alternative medications or therapies have been attempted or a reason given why they should not need to be attempted in this case.
When a prior authorization from the prescriber is needed, the claims processor will initially reject the healthcare transaction and inform the patient, by way of the service provider and the pharmacist and via a rejected adjudicated healthcare transaction response, that the rejection is due to a prior authorization requirement. The service provider may offer the patient and pharmacist a prior authorization assistance service to help satisfy the prior authorization requirement. However, in order to obtain this prior authorization assistance service, the pharmacist/pharmacy must reevaluate and make particular changes to the healthcare transaction which can be very disruptive to the workflow of and reduce the overall operating efficiency of the pharmacist and the pharmacy.